=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982072864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAVITY LABORATORIES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2015
-----------------------------------------------------
Last Update Date | 05/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24525 SOUTHFIELD RD STE 208
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-2740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-809-9371
-----------------------------------------------------
Fax | 888-392-6042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 37TH AVE N # 305
-----------------------------------------------------
City | SAINT PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33704-1416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-200-4882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | MR. ANTHONY REMINGTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-200-4882
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------